Method and device for urethral-vesicle anastomosis

ABSTRACT

An improved device and method are provided for securing the urethra to the bladder in surgery.  
     A trocar is provided for insertion into the urethra. The trocar is removably secured to the urethra for advancement of the proximal end toward the bladder. A sheath is inserted and secured to the bladder in order to assist in the advance of the bladder toward the urethra. The improved system permits medical personnel to clamp the urethra and bladder without the need for insertion of time consuming and laborious sutures. A method of securing the urethra and bladder using the disclosed apparatus is also provided.

RELATED APPLICATIONS

[0001] This application claims the benefit of U.S. ProvisionalApplication No. 60/144,429, filed Jul. 16, 1999, titled METHOD FORURETHRAL-VESICLE ANASTOMOSIS, the entirety of which is herebyincorporated by reference.

BACKGROUND OF THE INVENTION

[0002] 1. Field of the Invention

[0003] The present invention generally relates to the reconnection ofthe urethra and bladder after a radical retropubic prostatectomy.Specifically, the invention relates to a method and device forperforming a urethral-vesicle anastomosis.

[0004] 2. Description of the Related Art

[0005] In a radical retropubic prostatectomy, the surgeon removes all ormost of the patient's prostate. Because the urethra travels through theprostate immediately before reaching the bladder, the upper part of theurethra is removed in the surgery. In order to restore proper urinaryfunctions, the bladder and the urethra must be reconnected.

[0006] Heretofore, surgeons would execute painstaking suturingoperations with tiny, fine needles to reconnect these anatomical bodies.It has been found that the use of sutures for this purpose has causedcertain problems in recovery. These problems include necrosis of thesutured tissues, stricture of the urethra which impedes the flow offluid through it, and a urethra-bladder connection which is notfluid-tight. In addition, when suturing the urethra to the bladder thesurgeon often inadvertently pierces the nearby neurovascular bundle,which can cause incontinence or impotence.

[0007] The suturing process itself has also been found to be cumbersome,requiring the surgeon to grasp and stretch the bladder and urethratogether before making the fine sutures.

[0008] With radical retropubic prostatectomies becoming more common, aquicker and simpler way to reconnect the bladder and the urethra isneeded.

SUMMARY OF THE INVENTION

[0009] One aspect of the present invention is an improved method for theanastomosis of the urethra to the bladder following a prostatectomy.

[0010] A further aspect of the present invention is an anastomosisprocedure that eliminates the use of sutures in the urethra-bladderjunction.

[0011] A still further aspect of the present invention is an anastomosisprocedure with an improved means of grasping the urethra and bladder,bringing them together and holding them for the connection process.

[0012] A method and device are provided for the anastomosis of theurethra and bladder after radical retropubic prostatectomy. The surgeoninserts a trocar into the urethra and secures the bladder to the trocarwith an external ring, or, alternatively, with at least one prongassociated with the trocar. The surgeon then inserts a sheath into thebladder and secures the bladder to the sheath with at least one prong.The trocar and the sheath are then advanced toward each other, and fittogether in an end-to-end fashion. When the urethral tissue and thebladder tissue are in close proximity, the urethra and the bladder arereconnected using at least one clip. The urethra is secured to thebladder

[0013] In accordance with one preferred embodiment, a method is providedfor securing the urethra to the bladder of a patient. The methodcomprises the steps of inserting a first approximation device into theurethra, securing the urethra to the first approximation devicesinserting a second approximation device into the bladder and securingthe bladder to the second approximation device. The method furthercomprises the step of advancing the second approximation device towardthe first approximation device so that a distal end of the urethra comesin close proximity to a distal end of the bladder. The final step of themethod comprises securing the urethra to the bladder.

[0014] In accordance with yet another preferred embodiment, a method forsecuring the urethra to the bladder of a patient comprises the steps ofinserting a first approximation device into the urethra, securing theurethra to the first approximation device, inserting a secondapproximation device into the bladder and securing the bladder to thesecond approximation device. The method further comprises advancing thefirst approximation device and the second approximation device towardone another so that a distal end of the urethra comes in close proximityto a distal end of the bladder. Finally, the urethra is secured to thebladder.

[0015] In accordance with still another preferred embodiment, there isprovided a system for securing the urethra of a patient to the bladderof the patient. This system comprises a first approximation deviceadapted to be inserted into the urethra of the patient and a ring. Thering is suitable for placement on a exterior of the urethra for securingthe urethra to the first approximation device. The system furthercomprises a second approximation device adapted to be inserted into thebladder. The second approximation device has at least one prong on acannula of the second approximation device. The prong secures the secondapproximation device to the bladder. The system further comprises atleast one clip. The clip is suitable to secure the urethra to thebladder once the urethra and bladder are within close proximity.

[0016] In accordance with still another preferred embodiment, there isprovided a system for securing the urethra of a patient to the bladderof the patient. The system comprises of first approximation device thathas a generally rigid cannula and at least one prong. The prong ismoveable from a retracted position to an extended position on a exteriorsurface of the cannula to secure the urethra to the first approximationdevice. The system also comprises a second approximation device that hasa generally rigid cannula and at least one prong. The prong is moveablefrom a retracted position to an extended position on an exterior surfaceof the cannula to secure the bladder to the second approximation device.

BRIEF DESCRIPTION OF THE DRAWINGS

[0017]FIG. 1 is a schematic view of a trocar and sheath as used to jointhe bladder and urethra in accordance with the present invention;

[0018]FIG. 2 is a cross-sectional view of the trocar and sheath, and thejuncture of the bladder and urethra;

[0019]FIG. 3 is a side elevation view of a sheath;

[0020]FIG. 4 is a perspective view of a sheath;

[0021]FIG. 5 is a close-up perspective view of the distal end of asheath;

[0022]FIG. 6 is a side cross-sectional view of a sheath;

[0023]FIG. 7 is a detail cross-section view of the proximal end of asheath;

[0024]FIG. 8 is a second detail cross-section view of the proximal endof a sheath, oriented 90° to the view in FIG. 7;

[0025]FIG. 9 is a detail cross-section view of the distal end of asheath;

[0026]FIG. 10 is a perspective view of another embodiment of a trocar inaccordance with the invention;

[0027]FIGS. 11A and 11B are cross-sectional views of the joining of thebladder and urethra tissues, employing another embodiment of the trocarand sheath;

[0028]FIG. 12 is a perspective view of a dual approximator;

[0029]FIG. 13 is a perspective view of a dual approximator, with thebladder everting device displaced in the distal direction;

[0030]FIG. 14 is a cross-sectional view of a dual approximator;

[0031]FIG. 15 is a detail cross-sectional view of the proximal end of adual approximator;

[0032] FIGS. 16A-16C are side elevation, side cross-section, andperspective views of a bushing and everting wire assembly for use with adual approximator;

[0033]FIG. 17 is a detail cross-sectional view of the distal end of adual approximator; and

[0034]FIG. 18 is a cross-sectional view of the use of the dualapproximator to join the bladder to the urethra.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT

[0035]FIG. 1 depicts, among other things, the relevant anatomicalstructures of a patient following a radical retropubic prostatectomy.The urethra 10 has been separated from the bladder 12 by virtue of theremoval of the prostate (not shown). The urethra 10 must therefore bere-attached to the bladder 12 at the bladder outlet 14.

[0036] To rejoin the bladder and urethra, a urethra approximation trocar16, comprising a proximal end 18 and a tapered distal end 20, may beinserted into the urethra 10 via the urethral outlet in a manner knownto those skilled in the art. The trocar 16 is preferably constructed ofa stiff plastic or metal to provide sufficient rigidity despite across-sectional area small enough to permit the trocar 16 to passthrough the urethra. The trocar 16 is advanced within the lumen of theurethra 10 so that the tapered or rounded distal end 20 of the trocar 16emerges from the urethral passage. The urethra 10 is then secured to thetrocar 16 in a manner which will prevent the urethra 10 from slidingbackwards, away from the tapered distal end 20 of the trocar 16, whenthe trocar is subsequently advanced toward the bladder 12. Preferably,this is accomplished by a removable external ring 22 placed around theurethra 10 near the distal end 20, securing the urethra 10 to the trocar16. Another method to secure the urethra with respect to the trocar isby means of one or more everting prongs extendable from the outersurface of the trocar 16 near the distal end 20. (This is similar to theeverting prongs 30 extendable from the sheath 24, the operation of whichwill be discussed in greater detail below.) The prongs evert the urethratissue from the trocar shaft, pushing it out radially to facilitateattachment.

[0037]FIG. 1 also depicts a urethra approximation sheath 24 having aneverting knob 26 on the proximal end 28 and multiple everting prongs 30near the distal end 32. The distal end 32 also forms a cavity 34 whichis sized so as to snugly receive the tapered end 20 of the trocar 16(see FIG. 2). As with the trocar 16, the sheath 24 is preferablyconstructed of a stiff plastic or metal to provide sufficient rigiditydespite a cross-sectional area small enough to permit the sheath 24 topass through the bladder outlet 14.

[0038] To insert the sheath 24, the surgeon first makes an abdominalincision 36 to gain access to the bladder 12. The sheath 24, witheverting prongs 30 in a retracted position, is inserted into theincision 36 and is advanced toward the bladder outlet 14 so that thedistal end 32 of the sheath 24 emerges from the bladder outlet 14. Bymanipulation of the everting knob 26, the everting prongs 30 areextended from the sheath 24 and positioned inside the bladder 12 suchthat they engage the bladder tissue near the bladder outlet 14, securingthe bladder 12 with respect to the sheath 24. The everting prongs 30thus prevent the bladder 12 from sliding backward on the sheath 24, awayfrom the distal end 32 of the sheath 24, when the sheath 24 issubsequently advanced toward the urethra 10. In addition, the evertingprongs 30 pull the tissue of the bladder 12 both longitudinally andradially to facilitate the eventual application of one or more clips tothe junction of the bladder and urethra (see FIG. 2).

[0039] With further reference now to FIG. 2, the surgeon advances thesheath 24 toward the trocar 16, stretching the bladder 12 in theprocess. In one embodiment, the surgeon also moves the trocar 16 towardthe sheath 24, stretching the urethra 10 in the process. When the trocar16 and the sheath 24 meet, the tapered distal end 20 of the trocar 16enters the cavity 34 in the distal end 32 of the sheath 24, to an extentsufficient to enable the urethral tissue and the bladder tissue to presstogether as shown. Fit together in this manner, the trocar 16 and thesheath 24 can retain the tissues in this orientation suitable for theconnection process, in a “hands-free” manner. The tissues of the urethra10 and the bladder 12 are subsequently clamped together using one ormore external clips 38, around the circumference of the urethra-bladderattachment. The application of the clips may effect disengagement of thebladder tissue 12 from the everting prongs 30. In one embodiment, VCSclips are used to secure the urethral tissue to the bladder. The clips38 may be applied either individually, or simultaneously in a “one-shot”fashion.

[0040] After the application of the clips 38, the external ring 22 isremoved, releasing the trocar 16 from the urethra 10. The surgeon is nowable to remove the trocar 16 via the urethral outlet in a manner knownto those skilled in the art. Similarly, the sheath 24 may be moved inthe proximal direction, after retracting the everting prongs 30 bymanipulation of the everting knob 26. The sheath 24 exits the bladder 12through the incision 36.

[0041] FIGS. 3-9 show the components of the sheath 24 in detail. Thesheath 24 has an elongated cannula 40 with a cavity 34 in the distal end32 and an everting knob 26 near the proximal end 28. FIGS. 3, 4 and 6show a sheath 24 which is straight; advantageously, the sheath may becurved as seen in FIG. 1, to promote ease of insertion and use.(Similarly, the straight instruments seen in FIGS. 10, 12, 13 and 14 mayalso be curved, to obtain the same advantages.) The everting knob 26engages threads 42 near the proximal end of the sheath so that rotatingthe everting knob 26 causes it to advance in the desired direction(either distally or proximally) along the threaded portion of the sheath24. Knurling 44 is provided on both the cannula surface and the evertingknob to facilitate easy gripping of the knob and sheath during surgery.Best shown in FIG. 5, a number (preferably 4-6) of openings 46 aredistributed radially about the circumference of the cannula 40, near thedistal end 32. The openings 46 permit everting prongs (not shown) toextend from, or retract into, the cannula 40 when the everting knob 26is rotated.

[0042] As seen in FIG. 6, an everting tube 48 is disposed within a lumen50 of the cannula 40 and is coaxial with the cannula 40. The evertingtube 48 fits snugly within the lumen 50 but can easily movelongitudinally within the cannula 40 in both the distal and proximaldirections. Near its proximal end the lumen 50 widens at a neck 52 totake on a larger-diameter cross section proximal of the neck 52.Correspondingly, the everting tube 48 widens to form a stub 54 disposedwithin the larger-diameter portion of the lumen 50. The neck 52 coactswith the stub 54 to limit the travel of the everting tube 48 in thedistal direction.

[0043]FIGS. 7 and 8 show the proximal end 28 of the sheath 24 in detail.Note that FIGS. 7 and 8 are oriented 90° with respect to one another, sothat FIG. 7 may be considered a side view and FIG. 8 a top view. Alongitudinal slot 56 is formed in the wall of the cannula 40 near theproximal end 28. The slot 56 permits an allen screw 58 to extend from athreaded hole 60 in the stub 54 beyond the external wall of the cannula40 and into a space 62 formed by a radial groove 64 in the everting knob26, between distal and proximal walls 66, 68.

[0044] With the screw 58 in place, one can cause the everting tube 48 tomove in either the distal or proximal direction by manipulating theeverting knob 26. If the everting knob 26 is rotated so as to advance inthe distal direction, the proximal wall 68 of the radial groove 64 bearson the screw 58 as the everting knob advances distally, causing theeverting tube 48 to move distally within the lumen 50. Similarly, if theeverting knob 26 is rotated so as to advance in the proximal direction,the distal wall 66 of the radial groove 64 will bear on the screw 58,causing the everting tube 48 to move proximally within the lumen 50.

[0045] Referring momentarily to FIG. 6, it can be seen that the distalend of the everting tube 48 is connected to a bushing 70, which isdisposed within the lumen 50 and is moveable both distally andproximally therein. Best seen in FIG. 9, the bushing 70 forms alongitudinal socket 72 and two threaded holes 74 intersecting the socket72. The socket 72 receives the proximal ends of a number of evertingwires 76, and screws 78 threaded into the holes 74 clamp the evertingwires 76 into the bushing 70.

[0046] The everting wires 76 extend distally from the bushing 70 intoangled channels 80 that correspond to the openings 46 in the distal endof the cannula 40. The angled channels 80 force the distal ends of theeverting wires, when moved distally, to extend from the cannula so as toform everting prongs 30 (see FIG. 2). Similarly, the everting wires 76retract into the angled channels 80 when moved proximally.

[0047] Thus it can be seen that rotation of the everting knob 26 in thedesired direction will extend or retract the everting prongs 30. Whenthe everting knob 26 is rotated in a direction causing the everting tube48 to move distally, the everting tube 48 pushes the bushing 70 in thedistal direction, forcing the everting wires 76 to extend from theopenings 46 and form everting prongs. By rotating the everting knob 26in the opposite direction, the everting tube 48 moves proximally andpulls the bushing 70 proximally as well, causing the everting wires 76to retract into the angled channels 80.

[0048]FIG. 10 shows an alternative embodiment of the trocar 16, whichemploys the same everting-prong mechanism as the sheath discussed above.This type of trocar also has a tapered distal tip 20 which fits snuglyinto the cavity formed in the distal end of the sheath.

[0049]FIG. 11A depicts the use of the everting-prong mechanism of thesheath 24 with the bladder tissue 12. Additionally, FIG. 11A shows theuse of that version of the trocar 16 employing a similar mechanism, withthe urethra 10. After positioning the distal end 32 of the sheath 24near the bladder outlet 14, the surgeon extends the everting prongs 30,which engage the bladder tissue 12, everting the bladder outlet 14 aridholding it in a suitable position for attachment to the urethra 10. Whenusing a trocar 16 equipped with everting prongs 30, the surgeon insertsthe trocar 16 into the urethra 10 and positions the distal end 20 nearthe opening of the urethra 10. In a similar manner the everting prongs30 are extended so as to evert the tissue near the end of the urethra 10in the desired position for reattachment.

[0050] After everting both the bladder and urethra tissue, the surgeonbrings the trocar 16 and sheath 24 together so that the tapered distalend 20 of the trocar 16 fits into the cavity 34 of the sheath, and thebladder and urethra tissue meet. Upon joining the trocar and sheath, thesurgeon has both hands free to perform final alignment of the bladderand urethra tissue, and apply the clips 38 as shown in FIG. 11B.

[0051] FIGS. 12-14 show yet another embodiment of the instruments to beused in the present invention. This embodiment enables a surgeon toperform the operation without making an incision in the bladder(otherwise needed to insert the sheath) by combining the functions ofthe trocar and the sheath in a dual approximator 100 to be usedtransurethrally.

[0052] The dual approximator 100 has an elongated cannula 102 with arounded distal end 104, two sets of openings 106 in the surface of thecannula 102 for the bladder and urethra everting prongs 108, 110, and abladder everting knob 112 and a urethra everting knob 114 near theproximal end. As seen in FIG. 13, The cannula 102 is separable at apoint 116 between the two sets of openings 106, into a bladder evertingunit 118 and a urethra everting unit 120. This separation featurepermits the bladder everting unit 118 to move distally, into the bladderopening as necessary. Preferably, the bladder and urethra evertingprongs 108, 110 are radially staggered with respect to one another sothat the two sets of prongs will not “collide” when extended.

[0053] The urethra everting unit 120 resembles the sheath describedabove, with some additions best seen in FIG. 14. A central channel 122runs along the centerline of the urethra everting unit 120, through thedistal end 124, bushing 126, everting tube 128 and stub 130. A bladdereverting knob 112 is located proximal of a urethra everting knob 114,and engages threads on the outer surface of the cannula 102 so thatrotation of the bladder everting knob 112 causes it to advance in thedesired direction (either distally or proximally) along the threadedportion of the cannula 102. Best seen in FIG. 15, a radial channel 134,longitudinal slot 136, screw 138, and block 140 coact in a mannersimilar to that disclosed above with respect to the everting knob 26 onthe sheath 24, to cause the block 140 to move longitudinally within thelumen 142 of the cannula 102 in response to rotation of the bladdereverting knob 112 in the desired direction.

[0054] Attached to the block 140 is a bladder everting rod 144 whichruns through the central channel 122 and out the distal end 124,continuing into the bladder everting unit 118 (see FIG. 14). Toaccommodate the central channel 122 and bladder everting rod 144, thebushing 126 is modified as shown in FIGS. 16A-16C, and 17. Urethraeverting wires 146 are bent 90° at the proximal ends and are received inslots 148 formed at the distal end of the bushing 126. The centralchannel 122 and the bladder everting rod 144 (best seen in FIG. 17) passthrough the bushing 126, and the bladder everting rod 144 continuesdistally through a space 150 formed between the urethra everting wires146. This arrangement of the bushing 126 and urethra everting wires 146permits the bladder everting rod 144 and urethra everting wires 146 tomove freely with respect to each other within the cannula 102 withoutinterference.

[0055] Referring again to FIGS. 12-14, the bladder everting unit 118 islocated at the distal end of the dual approximator 100, and has arelatively short cannula 152 with a lumen 154 and a rounded distal tip104. The proximal end 156 is tapered, in the same way as the distal endof the trocar 16, to fit within the cavity 158 formed in the distal end124 of the urethra everting unit 120. Near the proximal end 156 arelocated a number (preferably 4-6) of openings 106 distributed radiallyabout the circumference of the cannula 152. As seen in FIG. 17, thecentral channel 122 continues from an opening 160 in the proximal tip,along the longitudinal axis of the bladder everting unit 118, to theproximal end of the lumen 154.

[0056] A bushing 162 is disposed within the lumen 154 and is moveableboth distally and proximally therein. The bladder everting rod 144passes through the central channel 122, into the lumen 154, and to thebushing 162. The bushing 162 forms a longitudinal socket 164 and twothreaded holes 166 which intersect with the socket 164. The socket 164receives the distal ends of a number of bladder everting wires 168 andthe bladder everting rod 144, and screws 170 threaded into the holes 166clamp the wires 168 and rod 144 into the bushing 162.

[0057] The bladder everting wires 168 extend proximally from the bushing162 into angled channels 172 corresponding to the openings 106 in theproximal end of the bladder everting unit 118. The angled channels 172force the proximal ends of the everting wires 168, when movedproximally, to extend from the cannula 152 so as to form everting prongs108. Similarly, the bladder everting wires 168 will retract into theangled channels 172 when moved distally.

[0058] Thus, by reference especially to FIGS. 14 and 17, it can be seenthat rotation of the bladder everting knob 112 in the desired directionwill extend or retract the bladder everting prongs 108. When the bladdereverting knob 112 is rotated in a direction causing the bladder evertingrod 144 to move proximally, the bladder everting rod 144 will pull thebushing 162 in the proximal direction, forcing the bladder evertingwires 168 to extend from the openings 106 and form bladder evertingprongs 108. By rotating the bladder everting knob 112 in the oppositedirection, the bladder everting rod 144 moves distally and pushes thebushing 162 distally as well, causing the bladder everting wires 168 toretract into the angled channels 172.

[0059] The bladder everting knob 112 also expands or contracts thedistance between the urethra everting unit 120 and the bladder evertingunit 118. When the bushing 162 in the bladder everting unit 118 remainsrelatively immobile, rotation of the bladder everting knob 112 so as tomove the bladder everting rod 144 distally or proximally, causes acorresponding distal or proximal movement of the bladder everting unit118.

[0060]FIG. 18 details the use of the dual approximator 100 in performingthe anastomosis procedure. The surgeon inserts the dual approximator 100into the lumen of the urethra 10, through the urethral outlet, in amanner known to those skilled in the art. The dual approximator 100 isadvanced within the lumen of the urethra 10 until the distal end of thedual approximator 100, including the bladder everting unit 118, emergesfrom the opening. Next the surgeon rotates the bladder everting knob soas to move the bladder everting unit 118 distally and create a suitablegap between the bladder everting unit 118 and the urethra everting unit120. The bladder everting unit 118 is then inserted into the bladderopening 14, to a point where the openings 106 in the bladder evertingunit 118 are properly aligned within the bladder 12. The surgeon thenrotates the bladder everting knob to extend the bladder everting wires168 from the openings 106, forming everting prongs 108, until the tipsof the prongs 108 contact and evert the bladder tissue 12. Similarly,the surgeon rotates the urethra everting knob to evert the end of theurethra 10 as desired. The surgeon then brings the everted bladder andurethra tissue 12, 10 together by further rotating the bladder evertingknob until the tapered proximal end 156 of the bladder everting unit 118meets the cavity 158 in the distal end of the urethra everting unit 120.At this point the surgeon will have both hands free to perform finalalignment of the bladder and urethra tissue 12, 10, and apply the clips38 in a similar manner as shown in FIG. 11B. After applying the clips38, the surgeon rotates the bladder everting knob to retract both setsof everting wires, and then withdraws the dual approximator 100 from theurethra 10.

[0061] The clips 38 perform a holding function, in a manner similar tosutures but without penetration of the vessel walls. One example of asuitable clip for use in this procedure is disclosed in U.S. Pat. No.4,983,176, titled DEFORMABLE PLASTIC SURGICAL CLIP, the entirety ofwhich is hereby incorporated herein by reference.

[0062] The present invention utilizes a simple, effective mechanicalarrangement for reconnecting the bladder to the urethra. By eliminatingthe painstaking, cumbersome suturing techniques, urethral-vascularanastomosis techniques are improved. Furthermore, in the disclosedprocedure, there is provided improved apparatus for grasping andeverting the urethra and bladder tissues, leaving the surgeon's handsfree for performing the reconnection step of the anastomosis process.

[0063] By utilizing the disclosed techniques and apparatus, the numberof steps in the anastomosis procedure is decreased, minimizing cost andreducing the required time for the procedure. The present inventioneliminates many complications associated with other anastomosistechniques, such as stapling or suturing. Because the clips do notpenetrate the vessel walls, there is a decreased likelihood of clotting,which may cause stricture. The clips also reduce the occurrence ofnecrosis, which occurs when insufficient blood is supplied to the joinedtissues. In addition, the use of clips eliminates the possibility ofpiercing the neurovascular bundle with the suture needle(s), whichpiercing can cause impotence and/or incontinence.

[0064] Although this invention has been disclosed in the context ofcertain preferred embodiments and examples, it will be understood bythose skilled in the art that the present invention extends beyond thespecifically disclosed embodiments to other alternative embodimentsand/or uses of the invention and obvious modifications and equivalentsthereof. Thus, it is intended that the scope of the present inventionherein disclosed should not be limited by the particular disclosedembodiments described above, but should be determined only by a fairreading of the claims that follow.

What is claimed is:
 1. A method for securing the urethra to the bladderof a patient, the method comprising the steps of: inserting a firstapproximation device into the urethra; securing the urethra to the firstapproximation device; inserting a second approximation device into thebladder; securing the bladder to the second approximation device;advancing the first approximation device toward the second approximationdevice so that a distal end of the urethra comes in close proximity to adistal end of the bladder; and securing the urethra to the bladder. 2.The method as in claim 1, further comprising the step of placing thefirst approximation device and the second approximation device infitting engagement before securing the urethra to the bladder.
 3. Themethod as in claim 1, wherein the step of securing the urethra to thebladder comprises applying at least one clip.
 4. The method as in claim1, wherein the step of securing the urethra to the bladder comprisesapplying at least one VCS clip.
 5. The method as in claim 3, wherein thestep of applying at least one clip comprises applying multiple clipssimultaneously.
 6. The method as in claim 3, wherein the step ofapplying at least one clip to secure the urethra to the bladdercomprises applying multiple VCS clips simultaneously.
 7. A method forsecuring the urethra to the bladder of a patient, the method comprisingthe steps of: inserting a first approximation device into the urethra;securing the urethra to the first approximation device; inserting asecond approximation device into the bladder; securing the bladder tothe second approximation device; advancing the second approximationdevice toward the first approximation device so that a distal end of theurethra comes in close proximity to a distal end of the bladder; andsecuring the urethra to the bladder.
 8. A method for securing theurethra to the bladder of a patient, the method comprising the steps of:inserting a first approximation device into the urethra; securing theurethra to the first approximation device; inserting a secondapproximation device into the bladder; securing the bladder to thesecond approximation device; advancing the first approximation deviceand the second approximation device toward one another so that a distalend of the urethra comes in close proximity to a distal end of thebladder; and securing the urethra to the bladder.
 9. A system forsecuring the urethra of a patient to the bladder of the patient, thesystem comprising: a first approximation device adapted to be insertedinto the urethra of the patient; a ring, the ring being suitable forplacement on an exterior of the urethra for securing the urethra to thefirst approximation device; a second approximation device adapted to beinserted into the bladder, the second approximation device having atleast one prong on a cannula of the second approximation device, theprong securing the second approximation device to the bladder; and atleast one clip, the clip being suitable to secure the urethra and thebladder once the urethra and bladder are within close proximity.
 10. Asystem for securing the urethra of a patient to the bladder of thepatient, the system comprising: a first approximation device having agenerally rigid cannula and at least one prong, the prong being moveablefrom a retracted position to an extended position on an exterior surfaceof the cannula to secure the urethra to the first approximation device;and a second approximation device having a generally rigid cannula andat least one prong, the prong being moveable from a retracted positionto an extended position on an exterior surface of the cannula to securethe bladder to the second approximation device.
 11. The system as inclaim 10, wherein the first approximation device has a first mating endand the second approximation device has a second mating end, the firstmating end and the second mating end being adapted to receive oneanother so as to place the first approximation device and the secondapproximation device in end-to-end fitting engagement.
 12. The system asin claim 10, further comprising at least one clip, the clip beingsuitable to secure the urethra and the bladder once the urethra andbladder are in close proximity.
 13. The system as in claim 11 whereinthe at least one clip comprises at least one VCS clip.